The idea of performing minor office-based urological procedures in young children may not sound like an exciting idea to many but can offer several important benefits to the children including avoiding the risks associated with general anesthesia, reduction in cost and associated financial burden on the family, and low complication rates. There has been excellent safety and efficacy reported on several office procedures commonly performed in pediatric urology including newborn circumcisions, urethral meatotomy, lysis of penile adhesions/skin bridges, lysis of labial adhesions and excision of benign lesions.^1,2 The increasing advancement of safe and effective local anesthetic agents has led to the shift of traditionally performing these procedures under general anesthesia to an office setting (Fig. 1). At Children’s Hospital of Philadelphia, we believe we have avoided general anesthesia in children by performing nearly 500 urological procedures every year in the office with reported high success rates and high patient satisfaction rate. While the trend in increased adoption of office procedures in pediatric urology continues, the obvious concerns of patient discomfort and pain are important factors to understand and address.

Strategies in Process

We believe there are several important factors to consider in order to ensure a safe, comfortable and satisfactory office procedure that limits pain in the child and eases the family. It is essential to create a supportive and comfortable office setting to entail mutual trust between the care team, child and family. A collaborative shared decision making approach with the family is a vital aspect of informed consent, particularly for office based awake procedures. Families should be counseled on the risks and benefits of undergoing the same procedure in both the office setting and under general anesthesia in an unbiased manner, making sure the family understands that it’s their choice rather than the will of their surgeon that determines the course of treatment. Another extremely valuable tool is an interdisciplinary approach that utilizes child life services and patient care advocates in the decision making process and during the procedures. They can help engage the child with playful interactions and digital media, address any patient discomfort or anxiety, and act as a conduit to express parental and/or patient concerns to the care team and thus best engage the family during the procedure (Fig. 2). In addition to education on the diagnosis and treatment options, it is important to reassure the family that a procedure in the office will be stopped at any time if the child or parent feels discomfort or reluctance, thus ensuring the family and child feel that they are in the driver’s seat. All team members present in the procedure should be perceptive of any verbal or physical cues from the child or parent that will warrant immediate stopping of the procedure. In addition, an institutional adoption of a multimodal approach to pain management is essential for optimal care.

Figure 1. Exam room setup for office-based circumcision including Gomco clamp.

Figure 2. Simple distractions including toys and books to help children feel more comfortable during office-based procedures.

To ensure smooth office workflow and optimize patient experience, after application of topical anesthetic we ask the patient and family to engage in playful activities in the waiting area until the full effect takes place, often lasting 30 to 45 minutes. This avoids keeping the family in a closed patient visit room for a prolonged period, decreases anxiety by distraction by other activities and improves patient room usage efficiency for the practice. We encourage families to bring the child’s favorite toy or book to reduce stress and anxiety during this waiting time.

Outcomes

We recently reported our own institutional experience, highlighting a success rate of greater than 95% in nearly 1,500 office procedures performed in our office over a 5 year period, with 98.9% of the cohort avoiding the risks associated with general anesthesia.³ While literature continues to report higher success rates in several urological procedures in the pediatric setting, the difficulty of performing validated questionnaires in children due to patient age poses limitations in assessing true patient reported outcomes (PROs). A study by Smith assessing parent perception of discomfort in children undergoing office-based procedures showed that 96% of parents were satisfied with the decision to have their child undergo the procedure in the office instead of under general anesthesia.⁴ While proxy reported outcomes may be temporary substitutions for PROs in the pediatric setting, it is critical to further investigate the development and implementation of validated questionnaires that accurately report PROs in children. Robust data in PROs are important for prospective improvement and aid with surgical decision making, pre-procedure care and counseling, as well as maximizing patient outcomes.

Conclusion

Office-based procedures are an excellent alternative to general anesthesia that offers a safe, convenient and cost-effective approach to pediatric care. Successful office-based awake child procedure care will be influenced by numerous factors including shared decision making with the patient and family, interdisciplinary collaboration with child life services, informative counseling and multimodal pain management strategies. As the use of office-based procedures continues to grow in the field of pediatric urology, additional ways to improve care based on PRO feedbacks in pediatrics is critical and should be our natural next step.